What are the typical symptoms, red‑flag features, initial work‑up, and management of pulsatile tinnitus?

Pulsatile Tinnitus: Clinical Approach

Pulsatile tinnitus demands urgent imaging evaluation in nearly all cases because over 70% have an identifiable structural or vascular cause, and missing life-threatening entities like dural arteriovenous fistula or arterial dissection can result in catastrophic hemorrhage or stroke. 1

Typical Symptoms and Clinical Presentation

Core Symptom Characteristics

• Patients describe a rhythmic, throbbing, beating, or whooshing sound that is synchronous with their heartbeat, distinguishing it from continuous non-pulsatile tinnitus 2, 3
• The sound may be unilateral or bilateral, with unilateral presentation having higher likelihood of identifiable structural or vascular pathology 1
• Patients may report the sound is perceived from within the head or ear, and intensity may vary with position or physical maneuvers 2

Objective vs. Subjective Classification

• Objective pulsatile tinnitus (audible to the examiner on auscultation) is rare but strongly suggests vascular pathology requiring immediate workup 1
• Subjective pulsatile tinnitus (patient only) still warrants comprehensive imaging in nearly all cases, as identifiable pathology is found in 70-91% of patients 1

Red-Flag Features Requiring Urgent Evaluation

Life-Threatening Presentations

• Focal neurological deficits (weakness, numbness, visual changes, ataxia) suggest stroke, hemorrhage, or mass lesion and require emergent CT angiography 1
• Vision changes (especially in young overweight women with headaches) suggest idiopathic intracranial hypertension, the second most common cause of pulsatile tinnitus, which can lead to permanent vision loss if missed 1
• Severe headache with pulsatile tinnitus raises concern for arterial dissection, dural arteriovenous fistula, or intracranial hypertension 1

High-Risk Clinical Features

• Asymmetric hearing loss requires different imaging protocol and raises concern for retrocochlear pathology like vestibular schwannoma 1
• Vascular retrotympanic mass on otoscopy (red pulsatile lesion behind tympanic membrane) suggests paraganglioma or glomus tumor 1
• Relief with carotid or jugular compression suggests venous etiology (sigmoid sinus abnormalities, jugular bulb variants) or arterial dissection 1

Demographic Risk Factors

• Young, overweight women with migraines represent high-risk demographic for idiopathic intracranial hypertension 1
• Older patients with vascular risk factors have higher likelihood of atherosclerotic carotid disease (17.5% of cases) 4

Initial Work-Up: Systematic Approach

Step 1: Focused History

• Characterize the sound: pulsatile vs. non-pulsatile, unilateral vs. bilateral, continuous vs. intermittent 1
• Assess for red flags: focal neurological symptoms, vision changes, severe headache, asymmetric hearing loss 1
• Elicit positional variation: does neck turning, jugular compression, or head position change the sound? 1, 5
• Screen for systemic conditions: hypertension, cardiac arrhythmia, hyperthyroidism (can cause bilateral pulsatile tinnitus from increased cardiac output) 4, 3
• Psychiatric screening: use validated instruments to assess for anxiety and depression, as severe psychiatric illness with tinnitus carries suicide risk 1, 6

Step 2: Physical Examination

• Comprehensive otoscopic examination is mandatory to identify vascular retrotympanic masses (paragangliomas appear as red pulsatile lesions), cerumen impaction, or middle ear effusion 1
• Auscultation over the neck, periauricular area, and mastoid to detect objective tinnitus from vascular abnormalities 1
• Neurologic examination to identify focal deficits suggesting intracranial pathology 1
• Jugular/carotid compression test: relief of pulsatile tinnitus upon compression suggests venous or arterial cause 1

Step 3: Audiologic Testing

• Comprehensive audiologic examination (pure tone audiometry, speech audiometry, acoustic reflex testing) should be obtained within 4 weeks for any unilateral or persistent pulsatile tinnitus 1
• Audiometry identifies asymmetric hearing loss and guides hearing aid evaluation when sensorineural loss is present 1

Step 4: First-Line Imaging Selection

The imaging choice depends on otoscopic findings and clinical suspicion:

If Vascular Retrotympanic Mass on Otoscopy:

• High-resolution CT temporal bone (non-contrast) is first-line to evaluate for paragangliomas (16% of cases), glomus tumors, adenomatous middle ear tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, and aberrant vascular anatomy 1

If Normal Otoscopy:

• CT angiography (CTA) of head and neck with contrast using mixed arterial-venous phase (20-25 seconds post-contrast) is preferred first-line study, capturing both arterial and venous pathology in a single acquisition 1
• CTA detects:
  • Arterial causes: atherosclerotic carotid disease (17.5% of cases), arterial dissection, fibromuscular dysplasia, arteriovenous malformations 1, 4
  • Arteriovenous shunts: dural arteriovenous fistulas (8% of cases, can lead to hemorrhagic or ischemic stroke if untreated) 1
  • Venous causes: sigmoid sinus diverticulum/dehiscence, high-riding jugular bulb, prominent mastoid or condylar emissary veins 1
• Technical advantage: CTA source images can be reconstructed into dedicated temporal bone CT datasets, providing both vascular and bony detail without additional radiation exposure 1

Step 5: Second-Line Imaging (If CTA Negative but Suspicion High)

• MRI brain with contrast plus MR angiography/venography is reserved for cerebellopontine angle lesions, subtle vascular malformations not identified on CT/CTA, detailed sinus anatomy assessment, and evaluation for intracranial hypertension 1
• Time-resolved gadolinium-enhanced MRA with arterial spin-labeling provides high sensitivity and specificity for detecting dural arteriovenous fistulas 1

Common Causes by Frequency

Most Common Etiologies

• Atherosclerotic carotid artery disease (17.5% of cases) from turbulent flow 1, 4
• Paragangliomas and glomus tumors (16% of cases) – highly vascularized skull base tumors 1
• Idiopathic intracranial hypertension (10% of cases, second most common cause) associated with sigmoid sinus wall abnormalities 1, 4
• Dural arteriovenous fistulas (8% of cases) – life-threatening, can cause stroke if untreated 1

Other Important Causes

• Jugular bulb abnormalities (high-riding jugular bulb, sigmoid plate dehiscence) 1
• Sigmoid sinus diverticulum or dehiscence (commonly associated with intracranial hypertension) 1
• Superior semicircular canal dehiscence (bony defect allowing transmission of vascular sounds) 1
• Arteriovenous malformations (high-flow vascular lesions) 1
• Aberrant venous anatomy (persistent petrosquamosal sinus, abnormal emissary veins) 1

Management Approach

Treat the Underlying Cause

• Atherosclerotic carotid disease: medical management of vascular risk factors, consider endarterectomy or stenting for significant stenosis 1
• Dural arteriovenous fistula: endovascular embolization or surgical ligation (urgent referral to interventional neuroradiology) 1
• Arterial dissection: anticoagulation or antiplatelet therapy (urgent neurology consultation) 5
• Paragangliomas/glomus tumors: surgical resection, radiation therapy, or observation depending on size and symptoms 1
• Idiopathic intracranial hypertension: weight loss, acetazolamide, lumbar puncture, or venous sinus stenting (responds dramatically to treatment in nearly 100% of cases when truly pulsatile) 1
• Sigmoid sinus diverticulum: surgical repair or endovascular stenting in severe cases 1, 5
• Superior semicircular canal dehiscence: surgical repair if symptoms are debilitating 1

Symptomatic Management

• Hearing aids are first-line audiologic therapy with strong evidence for tinnitus relief when sensorineural hearing loss is documented 1
• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent tinnitus 5
• Education and counseling about tinnitus mechanisms, natural history, and management strategies should be provided at initial visit 1

What NOT to Do

• Avoid routine use of antidepressants, anticonvulsants, or anxiolytics for treatment without addressing the underlying cause 5
• Do not use dietary supplements (Ginkgo biloba, melatonin, zinc) as primary treatment 5
• Never dismiss pulsatile tinnitus as benign without imaging, as treatable and life-threatening causes are common 1
• Do not order imaging for bilateral, symmetric, non-pulsatile tinnitus without localizing features, as this represents low-value care 1

Critical Pitfalls to Avoid

Diagnostic Errors

• Missing dural arteriovenous fistula is life-threatening; requires high index of suspicion and appropriate vascular imaging, as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage 1
• Inadequate otoscopic examination leads to delayed diagnosis and inappropriate imaging selection, particularly for vascular retrotympanic masses (paragangliomas) 1
• Overlooking intracranial hypertension in young, overweight women with headaches can lead to permanent vision loss 1
• Dismissing pulsatile tinnitus as benign is a common pitfall, as pulsatile tinnitus almost always requires imaging evaluation due to identifiable causes in >70% of cases 1

Management Errors

• Delaying imaging in patients with red-flag features (focal deficits, vision changes, severe headache) can result in catastrophic outcomes 1
• Ordering wrong imaging modality (e.g., MRI when CT temporal bone is indicated for suspected paraganglioma) delays diagnosis 1
• Failing to screen for psychiatric comorbidity misses patients at risk for suicide who require prompt intervention 1, 6